- This study from the Massachusetts General Hospital Cancer Center examined data on 34,670 deceased nursing home residents with advanced cancer
- More than a third of the residents had comorbidities, 54% had moderate to severe cognitive impairment and 67% were severely functionally impaired
- Yet 36% of the residents experienced a potentially burdensome end-of-life transfer, defined as two or more hospitalizations or any ICU admission during the last 90 days of life
- Less than half of the residents used hospice in the last 90 days of life
Many older adults and their families consider acute care to be burdensome toward the end of life, according to multiple observational studies. Yet Daniel E. Lage, MD, MSc, fellow in hematology/oncology at the Massachusetts General Hospital Cancer Center, and colleagues report in Cancer that more than a third of U.S. nursing home residents with advanced cancer experience potentially burdensome transfers in the last 90 days of life.
Study Subjects and Methods
The researchers linked Medicare claims (January 2008 to December 2011) with the quarterly clinical assessments of U.S. nursing home residents. They identified 34,670 deceased adults, age ≥65, who had a poor-prognosis solid tumor and lived in a nursing home for ≥100 days. Many residents had comorbidities (29% CHF, 34% COPD, 35% diabetes), 54% had moderate to severe cognitive impairment and 67% were dependent in all ADLs.
Prevalence of Transfers
36% of the residents experienced a potentially burdensome end-of-life transfer, defined as two or more hospitalizations or any ICU admission during the last 90 days of life.
15,162 residents (44%) had no hospice care in the last 90 days of life. In that subgroup, factors significantly associated with transfers were black race, comorbidities, complete dependence in ADLs and chemotherapy in the last 90 days of life. Moderate to severe cognitive impairment or a DNR directive were linked to lower risk of transfers.
Risk factors were similar among the residents who used hospice, except cognitive impairment was not protective.
The most common reasons for hospitalization were kidney failure, dehydration and pneumonia, suggesting transfers may be avoidable with proper advanced care planning. The fact that DNRs were associated with fewer transfers reinforces that idea. Oncologists should collaborate with nursing home clinicians on how and when to hold discussions with residents about goals of care and transition to hospice.
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